ABDOMEN SURGICAL PROPOSITIONS.
In introducing a discussion on this theme at the last International Congress of Medicine, the author submitted the following propositions : ( 1) Surgical operations on the pancreas must take into ac count the function of the organ.
(2) Emaciation, presence of fat in the stools, sugar in the urine, bronzing of the skin, icterus and pain are the symptoms of most pancreatic affections.
(3) Anatomically complete extirpation of the pancreas is difficult.
(4) Pancreatic surgery has not advanced so rapidly as other departments of visceral surgery because of difficulty in diagnosis and of attacking the pathologic lesion early. At present every thing indicates that the tail rather than the head of the pancreas is the field for surgery.
(5) It has been proved experimentally that the pancreas may be entirely removed and the animal live. It has not been proved that this may be done in practice. The morbid process which might call for excision of the organ is usually not limited to it. Extirpation is not rational in tuberculous or syphilitic dis ease. Partial extirpation is proper as long as the canal of San torini is left.
(6) The most common tumors of the pancreas are cysts, hwmatic, retention, or hydatid. In these the cysts may be extir pated or incised. In extirpating a cyst the question of opening Wirsung's canal arises and the probable diversion of the pancre atic juice into the belly cavity. When a cyst is incised, it is pru dent to stitch its walls to the belly wound (marsupialization), or, if this is impossible, to close the sac with great care.
(7) Pancreatic calculi should be extracted.
(8) Necrosis of the pancreas may justify operation to re move dead fragments of the gland.
(9) In suppurative or gangrenous pancreatitis the rule is to abstain from operation during the acute stage. Later operation is useful and may be performed through one of three routes : (a) Lumbar, extraperitoneal route.
(b) Transpleural route.
(c) Median incision above the umbilicus.
The pus should be evacuated and, if necessary, infiltrated or dead portions of pancreas removed.
Chronic pancreatitis may lead to complications by ex erting pressure on the choledochus or pylorus. In such case operation is best directed against the liver or stomach and the obstruction evaded.
(i i) In pancreatic hernia following wounds, reduction and even fixation may be accomplished. The thoracic route is pref erable if the hernia is diaphragmatic.
(i2) In contusions and wounds, operation may be neces sary because of haemorrhage. Bleeding is stopped by sutures or ligatures and clots are removed.
( i3) Floating pancreas is known. Experimental pathology admits of the organ being fixed by suture.
( i4) In invagination of the pancreas, operation directed against the complications is permissible.
(15) When the opening between the pancreas and duode num is occluded, a new route may be made. If this is impossible, a pancreatic fistula may be established.
(i6) Pancreatic haemorrhage may occur without the exist ence of a wound ; it is dependent on disease, most commonly on gangrene. Treatment is the same as in traumatic haemorrhage.
(17) In cases of annular pancreas, the surgeon has so far abstained from operation ; but it might be necessary to divide the ring, or to overcome gastric or intestinal complications.
(18) Sutures placed in the pancreas are tolerated as well as in the kidney or liver.
(194) Wounds of the pancreatic canal may be closed by su ture, as in the case of the intestine. Threads should not be left in the canal for fear of calculi forming.
(20) Union of wounds takes place by the proliferation of pre-existing cells, especially of the fibrous-tissue cells.
(21) Pancreatic regeneration has certainly been observed.
(22) After complete excision of the pancreas, one notes great development of the glands of Galeati, and especially an increase of karykinesis in the epithelium, so that one may sup pose, according to Martinotti's experience, that they would suffice to replace the removed organ.
(23) Diversion of the pancreatic juice into the belly cavity does not always induce peritonitis, because absorption is rapid. Like bile, one believes, pancreatic juice is inoffensive when healthy, but the reverse when altered.
(24) In excising the pancreas always ligate before cutting, to prevent hmmorrhage and escape of juice. The cautery is ineffi cient and dangerous.